Education

Posture should be the subject of one out of every four blog posts I write because good posture is one of the cornerstones of successful pelvic floor rehabilitation. Your posture affects your prolapse and incontinence every waking hour that you are standing or sitting. Once you realize this, you can begin to understand the profound importance of mastering optimal standing and sitting posture.

There is a position in the physical therapy world called “neutral spine.” This is a position where you hold a soft, natural “S curve” of your spine. It is somewhere in between the extreme gymnasts posture that many women find themselves in, where their lower abdominals offer no support around the front side of their pelvis. Or the other extreme of the flat back, “buns tucked under posture” where their tail bone is so tucked under that their entire pelvis is actually tipped from its natural position to a more vertical position.

To find your neutral spine, first place your hands on your hips and begin to rock your pelvis. First rotate your pelvis so that you tuck your buns under as far as you can. This is one extreme. Now rotate your pelvis back, sticking your buns out like a gymnast. This is the other extreme. Now, from this gymnast position, draw your transversus abdominus (TA) muscle tight by pulling your belly button “up and in.” You will note how activating this muscle rocks your pelvis back ever so slightly, softening the sharp lumbar curve, and pulling you back to neutral spine position.

I recognize that this is not easy. We all have a tendency to get lazy and allow our bodies to be supported by locked joints. This may be easiest, but the human body is dynamic and not meant to be in a locked position. With this in mind, unlock your knees, unlock your pelvis, and open your hands up by rotating the palms of your hands to face forward. All of these subtle postural changes engage muscles, open neural pathways, and increase blood and oxygen flow throughout our bodies. This requires effort and constant awareness of your body. Initially it will have to be a conscious effort to get in front of a mirror and find your own neutral spine. Then, with consistent effort, neutral spine positioning will become your norm.

Now, let’s go through neutral spine in a sitting position. To achieve this, you want to be in a position where your knees are slightly lower than your hips if viewed from the side. This may require you to slide to the front edge of your chair so that your knees drop slightly. You can also use this measurement in choosing the correct size swiss ball for exercise or for sitting at your work station. By sitting so that your knees are slightly lower than your hips, you make it easy to roll forward onto your “sitting tripod” made up of your two sit bones and your pubic bone. Note that your sitting tripod does not include your tail bone! Your tail bone should be free from all pressure when sitting in neutral spine. This makes the car and the couch the two toughest places to sit with good posture. Optimal sitting posture is just that easy…find your tripod! Once you feel pressure on your pubic bone, you are automatically in neutral spine. This is simply positioning, not any muscle action at all.

So, now let’s talk about what neutral spine posture does specifically for our pelvic floor function. We talked about neutral spine posture being a dynamic position, so it requires both our multifidi muscles within our low back as well as our transversus abdominus muscles, which wrap around the front of our pelvis, to be engaged in order to hold this position. Our pelvic floor naturally co-contracts with these two muscles as our bodies’ deepest core stabilizers. Also, our pelvic floor is now set at a perfect length, with just the right amount of tension to allow for the strongest contraction it can give. If we stand with our tail bone tucked under, our pelvic floor is hanging way too loose and relaxed to respond with sufficient support when needed. Also, if we are standing in a gymnast posture, then our pelvic floor is stretched beyond its functional limits and it, again, cannot provide sufficient support when needed. However, when we are in neutral spine, with our tail bone in slight extension, then our pelvic floor muscles, stretching from our tail bone to our pubic bone, are at the perfect length/tension to give optimal support.

I hope this is useful information for all of you. I can’t stress the importance of posture enough. For many it may be the last missing piece of the puzzle that will lead you to greater improvement of your pelvic floor symptoms!

This blog is designed to convince you of the importance of focusing on a “one step at a time” approach to regaining control of your pelvic floor. The muscles that make up your pelvic basket are often unknown muscles. Quite simply, many of you know you have biceps and quadriceps, but have you heard of your obturator or your puborectalis, or even your gluteus medius (which is a different muscle than your gluteus maximus!)? Rehabilitating the pelvic floor begins first with discovering many of these smaller muscles and then training yourself to contract or engage these muscles through slow, subtle, controlled movements. The minute these movements become too big or too fast, our bodies automatically recruit our bigger muscles that like to take over. The problem is that these bigger muscles offer movement but not stability. This type of strengthening has its place but not in pelvic floor rehab.

Let me give you an example to clarify this point. Your multifidi are small muscles that lie deep under your back extensors and attach to individual segments of your spine. The Prone Multifidi Extension exercise that I coach you through in the 1st workout on the Hab It: DVD, requires very subtle movements designed to recruit and isolate these small multifidi muscles. This small rotation of your pelvis achieves segmental extension of your lumbar spine and, more importantly, your sacrum. The minute these extensions become too big, creating movement beyond your pelvis, you automatically recruit your big back extensors and glutes which like to take over. This allows a good percentage of your multifidi muscles to take a break, which results in us losing our muscle isolation and our segmental extension goal.

It is with this in mind that we need to slow down, isolate, control our deepest stabilizers, and get these pelvic basket muscles firing efficiently. Remember, I have talked in depth about the “root of our core,” the deepest three stabilizers of our body in previous blogs. http://hab-it.com/blog/?p=257 It is important that we regain control of these stabilizers before working bigger movements that will allow us to return to our normal recreational activities. So I caution any of you rushing through your pelvic floor/pelvic basket strengthening. You will continue to have symptoms UNLESS you learn to recruit your deep stabilizers first. This is why it is important to allow your body 4-6 weeks of training with the Hab It DVD, which will help you find and engage all the muscles of your pelvic basket, before rushing back to running, hiking or any other recreational activity.

Once you have developed good control of your pelvic basket, your work is not yet over. It is now your job to maintain this strength and stability for years to come. Just think, this means you will have better posture when you are 80 years old, you will prevent future back or hip problems, and you will prevent a re-occurrence of your pelvic floor dysfunction. Take note that continuing pelvic floor exercises for life doesn’t mean that you have to lie in front of the DVD for 20 minutes 3x/week, but that you are conscious of working pelvic floor exercises into your daily routine. This could be in the shower, before you get out of bed, or whenever it works for you. If you fail to remain consistent with exercise and posture, your pelvic floor symptoms will remind you just like a good coach!

The pelvic floor has a significant responsibility to help support our 3 pelvic organs and to hold enough tension to help control our bladder. The muscles that run from our pubic bone back to our tail bone, that span the area between our two sit bones, and that encircle the three openings from our pelvic outlet are our pelvic floor muscles. These muscles are “on” throughout our day, working against gravity and intra-abdominal pressure. They are expected to be consistent, but lack the sheer bulk to ever be “big, strong” muscles. So when many of you have asked me about various “Kegel exercisers” that you have read about or seen advertised that help strengthen these pelvic floor muscles, my answer is consistently that you don’t need them. There are a couple of ways you can enhance the strength of your pelvic floor muscles beyond the 2-step Kegel exercise.

The first is to strengthen the muscles that co-contract with the pelvic floor. Strengthening your pelvic floor can occur through improving the coordinated muscle activation of all the muscles attached to the pelvis. These muscle groups that all work together are: your low back extensors (multifidi), your low abs (transversus abdominus), your inner thighs (adductors), and your deep hip rotators (hip external rotators such as gluteus medius, obturators, etc.). Learning how to co-contract all of these muscles will significantly help the strength and function of your pelvic floor.

The second way to strengthen the pelvic floor muscles beyond what you can achieve through a 2-step Kegel exercise, is through internal electric stimulation. An electric stim unit helps improve your pelvic floor strength by maximizing the number of muscle fibers recruited. Often as we age, through prolonged inactivity or following muscle trauma, we are not able to voluntarily activate all of the available muscle fibers. These “dormant” fibers can often be re-awakened through artificial stimulation. An electric stimulation machine can jump start these fibers and get them firing voluntarily again. You can seek out a women’s health physical therapist in your area to begin an electric stimulation program or, if you prefer, you can order a home unit. The Kegel 8 home electric stim unit is the most popular device discussed on the prolapsehealth.com website. This website features many women who have tried several different treatments for weak pelvic floor muscles and give their candid review.

The final way to progress strength of your pelvic floor is to focus on your posture. It is important to keep a healthy tension in the muscle fibers that make up your pelvic floor, and holding neutral spine posture ensures optimal position for your pelvic floor, making it more effective. I will refer you to one of my previous posture blogs ( http://hab-it.com/blog/?p=191 ) to help you understand the importance of how we position our body throughout our day to maximize muscle activity.

All of these methods that you can use to strengthen your pelvic floor beyond the 2-step Kegel exercise are the perfect focus when rehabilitating your pelvic floor. Adding additional weight or resistance to these strengthening exercises is too much for this relatively thin group of muscles and will more than likely result in muscle spasms, poor muscle substitution patterns, and/or significant muscle fatigue that can all lead to increased symptoms. You can’t make a thin group of primarily endurance muscles into big bulky muscles no matter how hard you try.

If I could make a recording for you to play in your head throughout your day to help your pelvic floor symptoms, it would simply say, “Stick your buns out and draw your belly button up and in, stick your buns out and draw your belly button up and in.”

By following these simple instructions, you will set your pelvic basket to the best possible position. All of your key muscles will be at the perfect length and holding the perfect tension so that they can fire quickly and with optimal strength. These two cues will take you out of the “buns tucked under” position and will engage that loose belly pooch that a lazy posture can produce.

I can provide all the exercises in the world for you to work on to strengthen your pelvic floor and the many muscles of your pelvic basket, but the reality is that this strengthening only takes place within 20-30 minutes of our day. The remaining 16 hours that we are awake play a significant role in our pelvic floor function as well. So, the easiest way I can follow through with the progress I make through specific strengthening exercises is to hold optimal posture. A big part of optimal posture is the co-contraction of the multifidi muscles and the transversus abdominus (TA) muscle. I engage my multifidi muscles by sticking my buns out to assume a gymnast posture. I then soften my lumbar curve by drawing my belly button up and in, which engages my transversus abdominus. The co-contraction of these two muscles provides a stable lumbopelvic spine and solid anchors for my pelvic floor, my adductors, and my external rotators to pull on, offering optimal pelvic floor control!

So, set yourself up for success with these simple postural cues and consistent follow through throughout your day. “Stick your buns out AND draw your belly button up and in,” are two important steps to pelvic health.

This is an entry about the power of positive change. Often changing just one part of our daily routine will lead to another positive change. This may be making a change to our posture, a commitment to eating healthier food, or an increase in our activity level. It’s amazing how great we feel when we get caught up in the momentum of healthy habits. Instead of looking at this as a daunting task and lifestyle change that needs to be done all at once, just start with your posture and let the positive changes begin.

In the physical therapy world we often talk to patients about breaking the negative pain cycle that many fall into. The pain cycle works like this: pain leads to inactivity, which leads to weakness, which leads to dysfunction and more pain, which of course leads to continued inactivity and even more weakness and pain. The reality is that we can spiral into a healthy cycle just as we can this negative pain cycle.

With positive changes, we can gain momentum one step at a time, building on healthy habits. The cycle of positive change may look like this: Holding “good” (neutral spine) posture can lead to increased muscle activation, which leads to greater energy and increased activity, which can lead to healthier food choices, viewing food as fuel for your healthy body, which leads to feeling better about yourself and more consistent activity level with positive body changes, which will lead to more consistent healthy eating habits, activity, better posture, and so on.

You may think it is crazy to say that if you focus on holding optimal neutral spine posture throughout your day, in both sitting and standing positions, that this will lead to healthier eating habits, but I dare you to try! Review my postural instruction on YouTube http://www.youtube.com/user/PTPartners#p/u/3/hcTEUKp7zsY
and my blog http://hab-it.com/blog/?p=227 as a starting point. The healthy changes to follow will all benefit your pelvic muscles and their function.

As a starting point, focus on your posture from morning until night for one week and give us your feedback. Posture is a powerful change and an easy one to start with, so start today!

I was recently send the article below that was just published this month. This is big information about the efficacy of pelvic floor exercise and I would argue even more so from pelvic basket strengthening. Remember there is no side effect to exercise, so use it as a first line of defense! Read below:

From Reuters Health Information

By Fran Lowry

NEW YORK (Reuters Health) Sep 01 – Pelvic floor muscle training can reduce the symptoms of pelvic organ prolapse, according to trial data reported in Glasgow this week at the 41st Annual Meeting of the International Continence Society (ICS 2011).

“Health care professionals who see women bothered with symptoms of prolapse should counsel them to consider conservative treatment in the first instance and offer a referral for supervised PFMT,” lead author Dr. Suzanne Hagen, from Glasgow Caledonian University, Glasgow, Scotland, told Reuters Health.

Many physiotherapists do offer women with pelvic organ prolapse individualized pelvic floor muscle training (PFMT) but evidence of its long-term clinical benefit has been lacking.

In this multicenter randomized trial, Dr. Hagen and her team assigned 448 women with newly diagnosed prolapse of stage I, II, or III to receive either PFMT or a lifestyle advice leaflet which was sent to them in the mail. Women with stage IV prolapse, which is the most severe, were not included in the study.

The mean age in the study was 57 years. The median number of births was two, with most births (89%) being normal vaginal deliveries. Anterior prolapse was the most common type, affecting 34% of the women, followed by combined anterior/posterior prolapse (24%) and posterior prolapse alone (16%).

Most of the women (74%) had stage II prolapse, 15% had stage III, and 11% had stage I. The mean duration of prolapse symptoms was slightly more than two years.

The PFMT was delivered by a physiotherapist at five appointments over 16 weeks. At the visits, the women were taught about their pelvic floor muscles and how to exercise them. They were also given a home exercise program to follow between appointments.

“This is a similar program to that given for women with urinary incontinence, which is known to be effective,” Dr. Hagen said.

The women had follow-up visits at six and 12 months after they entered the study. The researchers found symptoms improved significantly more in the intervention group compared with controls.

The pelvic organ prolapse symptom score (POP-SS) was lower in the women who received PFMT at six months (6.56 vs. 9.17 for controls; P < 0.001) and at 12 months (5.74 vs. 7.04 for controls; P = 0.005).

The average decrease in POP-SS for the women who got PFMT was 1.52, “which represents an important change, clinically,” Dr. Hagen noted.

Additionally, women who attended all five appointments had a significant increase in contraction strength from baseline, according to the modified Oxford scale, with a mean increase of 0.6 (p

“We would hope that national evidence-based guidelines would be developed for the treatment of prolapse which would include the findings of this trial and the evidence for other treatments, such as surgery and pessaries,” Dr. Hagen said. “Also, we would hope that women can be counseled that if they wish to avoid surgery they may benefit from PFMT.”

We are excited to provide new exercises as a progression of our Hab It: Pelvic Floor DVD. The new 7-day workout was created at the request of many Hab It subscribers who have seen great success with the DVD, but want to further their pelvic floor and entire pelvic basket strength. Your goal may be to return to a fitness walking program, to return to hiking, triathlon, 5K’s, 10K’s, or other recreational activities.

This program will give you the core stability to resume regular training for your sport. It is a challenging program that guides you through seven different workouts, all focusing on the coordinated muscle contraction of the many muscles that make up your pelvic basket. You will note improved strength of your pelvic floor, transversus abdominus (TA), glutes, low back, inner thighs, and hip external rotators. Also, included in the workouts are strengthening exercises for postural muscles that are key components of pelvic floor stability. The exercises are provided in written and video format to ensure correct form as instructed by me, Tasha Mulligan, physical therapist, athletic trainer, personal trainer, and mom of three.

Please note that because of the advanced level of these stability exercises, it is recommended that you begin with good base strength of your pelvic basket by following the workouts on the Hab It: Pelvic Floor DVD consistently for 6 weeks. The advanced exercise program is not to be performed while pregnant and you should consult with your doctor before beginning the program if you have had a previous back, shoulder, or hip injury.

Why should this be your first line of defense? Well, why not learn more about your body? Why not learn how your posture can affect your pelvic symptoms? Why not learn, with hands-on, one-on-one treatment how to find and hold neutral spine posture to give your body the best opportunity for good health?

A women’s health physical therapist has many tools she can use to improve your pelvic symptoms. She may choose to use manual therapy, locating and releasing internal trigger points within your pelvic floor muscles. Electric stimulation may be appropriate if one or several of your pelvic floor muscles aren’t achieving full muscle contraction. She will provide patient education and strengthening exercises not only for your pelvic floor but also your transversus abdominus (TA), lower back, glutes, inner thighs and deep hip rotators. Finally, she will work with you on your postural positioning that will directly affect your pelvic symptoms
throughout your daily activities.

When searching for a women’s health physical therapist in your area, you can go to the “Resources” tab on our home page and then on the APTA Women’s Health link that will take you to the therapist locator. If you do not find a therapist in your area, then simply make some calls to the clinics in your area, asking if they have a Women’s Health Physical Therapist on staff. You can ask to talk to this therapist to find out more specifics about their mode of treatment.

Some questions you may ask would be, “Do you perform an internal initial exam?”, “Do you use an internal electric stimulation unit in treatment of pelvic disorders?”, “Do you teach strengthening of muscles beyond my pelvic floor?”, “What else can I expect during the course of my treatment at your clinic?”

Although women are beginning to seek answers and are getting more comfortable in demanding care for pelvic disorders, it can still be an uncomfortable topic for many women. Asking all of the above questions will help to set your expectations and better prepare you for your rehabilitation. That being said, the reality is that many women don’t want to seek outside help with their condition and prefer to remain private in their pelvic floor treatment. If this is your wish, then you have the option of the Hab It: Pelvic Floor DVD that can begin or enhance your journey through pelvic floor rehab within the privacy of your own home. This can be a great resource, written by a physical therapist, that will help you feel more confident and sure of your body, guiding you through postural education and specific exercise programs to not only strengthen your pelvic floor but your entire pelvic basket. When and if you are ready for manual treatment, you can confidently seek out a clinic and the hands-on treatment of a women’s health physical therapist. Remember, it’s your body, you are in control!

Following a previous blog entry, one of our Hab It subscribers posted an insightful comment. With her permission, I have posted it below:

“Thank GOD for you, Tasha. I have your DVD and I’m about 3 weeks into working steadily on the strengthening exercises. I have a uterine prolapse and like yourself (and a previous commenter) am an avid runner who truly does NOT want to give it up.

I was devastated when a doctor flippantly told me “well you’re done with that”.

I’m staying with the program. All tests have come back negative – no disease and no other issues – so I trust that my body will strengthen and recover.

Here’s something to consider – I’ve been taking supplemental magnesium for years. Started years ago for migraines, then bronchials, then sleep problems – yes magnesium helps all of those things (even constipation) so I have taken more on a regular basis every day. What I didn’t realize is how many smooth muscles it really affects. I believe the ultra – relaxing (plus active running) has contributed to my prolapse. I stopped the extra magnesium and started your program and have seen positive results in only a few weeks.

Just something to consider. We really do have to be our own doctors – at least our own ‘experts’ on our bodies.

On my first visit I was told I needed a total hysterectomy “immediately.” No other options. For a fit, healthy, non-diseased person. It was terrifying until I got online and spent days on end researching. Thank you for your DVD and all of the help you give online. Your sincerity just shines through – you truly want to help and you are thorough and knowledgeable and it really shows. I so appreciate what you’re doing!”

The message in this blog entry is to ask questions, to educate yourself, and to be cautious with what we put into our bodies. Many of us take supplements to improve our health, but because of the lack of thorough guidelines and recommended dosage information, we may be doing more harm than good.

I have asked a friend and registered nurse to give her input on this post. Feel free to ask any other questions you may have regarding Vitamin D, Fish Oil, Calcium or any other supplements you may take. Our expert will give her recommendations.

There are so many media outlets beginning to shed some light on the complications associated with pelvic surgery, more specifically, transvaginal mesh. Among the many articles, these are some examples:

These articles highlight many of the reported complications that are irreversible if the mesh erodes through the tissue of the vaginal wall or the tissue of any of the pelvic organs. Beyond the complications specifically associated with the mesh, the pelvis is an area of the body that is more likely to form adhesions following injury or surgery. These adhesions themselves can cause significant pain, increased symptoms of incontinence or prolapse, as well as spasms of the pelvic organs themselves.

The one option you have to resolve your symptoms with no side effects is exercise and posture. This is an option that allows you to help yourself and empower your own body to regain control of your pelvic floor and organ support.

Why not give your body an opportunity to heal naturally? The information you will find on the Hab It DVD, the Hab It blog, and on our Hab It YouTube Channel http://www.youtube.com/user/PTPartners will lead you down the road to recovery. We are happy to help you help yourself!